Munchausen syndrome by proxy: Clinical review and legal issues

Well-established policies and procedures govern the identification, management, and treatment of most variations of child abuse. For many therapists, such cases have become “routine”. Munchausen syndrome by proxy is an under-recognized form of child abuse in which a parent feigns or creates illness in a child specifically to have the child subjected to unnecessary diagnostic tests and treatments by medical practitioners. Variations range from false reports of fevers or allergies, to life-threatening abuse, such as surreptitious poisonings or injections with toxic substances. This article reports a case example of Munchausen syndrome by proxy, provides a review of historical, diagnostic and management issues, and discusses legal issues relevant to detection of the perpetrator and protection of the child victim.     

The child's experience of Munchhausen syndrome by proxy

This paper examines the emotional impact of Munchhausen syndrome by proxy on a child aged 6 who had been poisoned by her mother. It describes her treatment in child psychotherapy over twenty months at the Cassel Hospital where the family worked towards her successful rehabilitation home. The work with her showed her experience of dangerous relationships in her family that left her distrustful of any new relationship, and doubtful of her capacity to be close without being destructive. Like her parents, she was terrified of facing the murderous feelings in the family, retreating into denial when life was too painful. The paper describes three phases of treatment: fear of separation and preoccupation with the trauma of poisoning, ambivalence about facing the destructiveness in the family and the move into more appropriate latency behaviour as she prepared to go home with her parents. It concludes with an overview of the impact of Munchhausen syndrome by proxy on the developing child, as shown in this treatment: the delay in emotional and cognitive development, the interference with the capacity to relate, the retreat into illness under stress, and the fear of permanent damage caused by the emotional and physical abuse.     

"Munchausen syndrome" with variable, largely neurologic symptoms

The paper gives an account of a man, now 32 years old, who has exhibited the typical characteristics of a "Münchhausen Syndrome", increasing in intensity, since later childhood. The increasingly neurological-neurosurgical range of his predominantly simulated and manipulated complaints covers in the main seizures, attempted suicide, craniocerebral injuries, hemiplegia, and paraplegia. The patient has had four operations for a "Cauda Syndrome". The complex conditioning the complaint, and appropriate medical reaction, are discussed with critical reference to previous literature on the subject.     

The phenomenology of self-reported body dysmorphic disorder by proxy

Body dysmorphic disorder by proxy (BDDBP), a preoccupation with a perceived defect in another person's appearance may represent a variant of BDD. However, BDDBP has received little empirical attention. We present here the phenomenology of 11 individuals with self-reported BDDBP. Participants completed an internet-based survey that assessed symptoms, psychosocial impact, and treatment history. Participants (8 females, 3 males) reported preoccupation with a wide array of individuals (e.g., spouse, stranger). Body parts of concern most commonly involved the face and head. Most participants spent several (e.g., 3–8) hours per day preoccupied by perceived defects in the person of concern (POC). All participants engaged in rituals to try to alleviate distress or improve the POC's appearance. Most avoided social/occupational activities, including contact with the POC. The impact of BDDBP was profound, particularly on relationships. Findings may help elucidate diagnostic criteria, course, and treatment.     

Multi-agency family systems

The term 'multi-agency' family is preferred to 'disorganized' family. Multi-agency family systems present special problems of the relationships (a) within the family, (b) between family and professional network, (c) among members of the professional network and (d) between family, network and treatment centre to whom the family is referred. Pressures on the family and professional workers can create a locked system which prevents natural development of the family or effective problem solving by the workers. A systems approach to such problems is presented which includes consultation to the family/professional network system.     

Extreme itching treated by a family systems approach

A case study is presented in which a 16-year-old daughter developed extreme itching and scratching behavior that was triggered by the occurrence of manifested parental conflict. The daughter's scratching also served the family function of helping the parents avoid marital conflict. Family treatment consisted of helping the parents manifest, negotiate, and resolve marital conflict issues in front of the daughter so that she could experience the benefits of dealing with a family conflict in a functional way. This approach had helped the daughter decrease her anxiety about conflict situations which, in turn, has resulted in a significant decrease in her itching and scratching behavior. In addition, the parents report an improved marital relationship now that the daughter's itching no longer occurs and no longer interrupts the parents' attempts to negotiate marital conflict issues.1979, Fall     

Extreme itching treated by a family systems approach

A case study is presented in which a 16-year-old daughter developed extreme itching and scratching behavior that was triggered by the occurrence of manifested parental conflict. The daughter's scratching also served the family function of helping the parents avoid marital conflict. Family treatment consisted of helping the parents manifest, negotiate, and resolve marital conflict issues in front of the daughter so that she could experience the benefits of dealing with a family conflict in a functional way. This approach has helped the daughter decrease her anxiety about conflict situations which, in turn, has resulted in a significant decrease in her itching and scratching behavior. In addition, the parents report an improved marital relationship now that the daughter's itching no longer occurs and no longer interrupts the parents' attempts to negotiate marital conflict issues.     

Structural family therapy with Mexican-American family systems

Characteristics of traditional Mexican-American families with consequent family rules that affect these family systems are discussed along with selected clinical cases. The specific cases discussed involve: (1) interactions with family of origin in intercultural marriages, (2) intracultural differences in levels of acculturation and traditional family rules, and (3) extended family impact in response to severe life crisis. The development of therapeutic processes from structural and strategic family therapy approaches, which reflect appreciation for cultural differences and strengths, is suggested.This material was presented at the annual meeting of the Texas Association for Marriage and Family Therapy, January, 1994, San Antonio, TX.     

Formulations of self and family systems

The observations of systemic family therapy and self psychology fit together conceptually because both rest upon systems theory. Underlying assumptions common to both fields of inquiry are reviewed. The concept of the self and its parts is examined, with discussion of its systems properties featuring stability and change. Parallels are noted between healthy self-functioning and healthy family functioning; self-formation processes and family developmental processes; and sense of self and family paradigm. It is suggested that there are isomorphic patterns in these formulations that allow us to switch back and forth easily between the individual and the family. Two clinical case examples are also included.     

Near-death experience by proxy: A case study

A recent interview with a 34-year-old man, currently serving a life sentence for murder, revealed a remarkable case of near-death experience by proxy. The phenomenological features of the experience unfolded typically, with some slight variation in content. The immediate drastic changes in attitude and belief following the experience are described.Ms. Sutherland was formerly a lecturer in the Department of Social Work, University of Sydney.     

Psychoanalysis and systems in family therapy

This paper describes three frames of reference for understanding family function. The three frames are (1) The Life-cycle of the Family, (2) The Intergenerational, Historical Aspects of the Family, (3) The Interactional Structure of the Family. It is suggested that these three frames can provide a detailed formulation of family functioning and disturbance in order to plan rational foci, strategies, techniques and aims of family therapy.     

A family systems approach to grief

This article blends two important viewpoints on grief: a stage theory on the individual's grief and the family systems literature on grief. A case study is examined from both the individual and systemic viewpoints. Pastoral implications for intervention with the case study family as a system are noted. The theological questions which the family and pastor face are also discussed.     

The rainbow bridge: an approach to family systems via Howards End

Bateson's ideas of artistic expression, the continuity of Art and Science and the nature of Mind are used as cues for the exploration of Howards End, E. M. Forster's novel of family life. Illustrations of systemic concepts are given from the text. Particular relevance is suggested for the use of literary examples in family therapy training and in the development of family systems theory.     

Attachment within family systems: An overview

A family systems approach provides a context for the development and maintenance of dyadic attachment relationships. An attachment approach provides a focus on the expression of and response to attachment behavior within a family. Uniting the two approaches has implications for both research and intervention. Characteristics of attachment theory and family systems theory are briefly outlined: Both involve systemic thinking. Different styles of interacting at the level of the family as a whole, working models of relationships, and dyadic interactions appear to correspond in a coherent way. Further research is needed in order to identify which dimensions of family functioning are relevant to the development of secure attachments, and how the relevant dimensions may change with age and stage in the family life cycle. This will provide targets for preventive interventions, with the development of secure relationships as a primary goal.     

Value systems and psychopathology in family therapy

Two sets of values—the continuity and the discontinuity—are readily apparent in family conflict. Pathogenic relating erupts after an impasse between the sets of values. Husband-wife conflict, parent-child conflict, and conflict between the family and neighborhood or community are described in terms of conflict in value systems. Family therapy is a method for influencing the value systems.Each of the three role functions of the family therapist—the go-between, the side-taker, and the celebrant—expresses both continuity and discontinuity values which are described. Depending on his assessment of pathogenic relating and other features of family dysfunction, the therapist selectively expresses values that serve to disrupt and then repair destructive family interaction.The process of engaging families in therapy is crucial because many families, especially those that are poor and uneducated, do not like to sit and talk about problems. Short-term therapy works best with the majority of poor, uneducated families; it even works best with middle-class families. Short-term therapy works mainly because it least violates value expectations the majority of families have about therapy.An invited presentation for the First International Congress of Family Therapy held in Tel Aviv, Israel, in February, 1976. A brief version of this paper is scheduled forPsychotherapy: Theory, Research and Practice, Vol. 15, No. 1, 1978, but due to an extraordinary delay in publication of the above-named journal, the lengthier version here may actually appear in print first. The possibility is mutually acknowledged by the editors of both journals.     

Use of family systems in preparation for ministry

Understanding the systematic dynamics of one's family of origin is necessary in preparation for ministry and can be most powerfully effected by engaging students in one of several family therapy techniques. Moreover, a family systems orientation is useful for theological explorations regarding family and Church as family, as well as enhancing skills for ministering to the contemporary family in all its diversity.Dr. Anderson is Associate Professor of Pastoral Theology, Waterburg Theological Seminary, Dubuque, Iowa 52001. Dr. Fitzgerald is Chaplain Supervisor, Medical Center at Princeton, Princeton, New Jersey 08540. This article stemmed from a presentation made by the authors on November 11, 1977, at the annual Conference of the Association for Clinical Pastoral Education.     

Perceiving by proxy: Effect-based action control with unperceivable effects

Anticipations of future sensory events have the potential of priming motor actions that would typically cause these events. Such effect anticipations are generally assumed to rely on previous physical experiences of the contingency of own actions and their ensuing effects. Here we propose that merely imagined action effects may influence behaviour similarly as physically experienced action effects do. Three experiments in the response–effect compatibility paradigm show that the mere knowledge of action–effect contingencies is indeed sufficient to incorporate these effects into action control even if the effects are never experienced as causally linked to own actions. The experiments further highlight constraints for this mechanism which seems to be rather effortful and to depend on explicit intentions.